Medicaid; division shall seek waiver to allow coverage for additional eyeglasses within 5-year period for adults whose refraction has changed.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Crawford

HOUSE BILL NO. 1185

AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, 1
TO DIRECT THE DIVISION OF MEDICAID TO APPLY FOR A FEDERAL WAIVER 2
TO ALLOW COVERAGE FOR AN ADDITIONAL PAIR OF EYEGLASSES WITHIN A 3
FIVE-YEAR PERIOD FOR BENEFICIARIES WHO ARE TWENTY-ONE YEARS OF AGE 4
OR OLDER WHOSE REFRACTION HAS CHANGED WITHIN THE FIVE-YEAR PERIOD 5
AND A PHYSICIAN SKILLED IN DISEASES OF THE EYE OR AN OPTOMETRIST 6
HAS DETERMINED THAT A NEW PAIR OF EYEGLASSES IS NEEDED TO CORRECT 7
THE CHANGE IN REFRACTION; AND FOR RELATED PURPOSES. 8
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 9
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is 10
amended as follows: 11
43-13-117. (A) Medicaid as authorized by this article shall 12
include payment of part or all of the costs, at the discretion of 13
the division, with approval of the Governor and the Centers for 14
Medicare and Medicaid Services, of the following types of care and 15
services rendered to eligible applicants who have been determined 16
to be eligible for that care and services, within the limits of 17
state appropriations and federal matching funds: 18
(1) Inpatient hospital services. 19
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(a) The division is authorized to implement an All 20
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 21
methodology for inpatient hospital services. 22
(b) No service benefits or reimbursement 23
limitations in this subsection (A)(1) shall apply to payments 24
under an APR-DRG or Ambulatory Payment Classification (APC) model 25
or a managed care program or similar model described in subsection 26
(H) of this section unless specifically authorized by the 27
division. 28
(2) Outpatient hospital services. 29
(a) Emergency services. 30
(b) Other outpatient hospital services. The 31
division shall allow benefits for other medically necessary 32
outpatient hospital services (such as chemotherapy, radiation, 33
surgery and therapy), including outpatient services in a clinic or 34
other facility that is not located inside the hospital, but that 35
has been designated as an outpatient facility by the hospital, and 36
that was in operation or under construction on July 1, 2009, 37
provided that the costs and charges associated with the operation 38
of the hospital clinic are included in the hospital's cost report. 39
In addition, the Medicare thirty-five-mile rule will apply to 40
those hospital clinics not located inside the hospital that are 41
constructed after July 1, 2009. Where the same services are 42
reimbursed as clinic services, the division may revise the rate or 43
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methodology of outpatient reimbursement to maintain consistency, 44
efficiency, economy and quality of care. 45
(c) The division is authorized to implement an 46
Ambulatory Payment Classification (APC) methodology for outpatient 47
hospital services. The division shall give rural hospitals that 48
have fifty (50) or fewer licensed beds the option to not be 49
reimbursed for outpatient hospital services using the APC 50
methodology, but reimbursement for outpatient hospital services 51
provided by those hospitals shall be based on one hundred one 52
percent (101%) of the rate established under Medicare for 53
outpatient hospital services. Those hospitals choosing to not be 54
reimbursed under the APC methodology shall remain under cost-based 55
reimbursement for a two-year period. 56
(d) No service benefits or reimbursement 57
limitations in this subsection (A)(2) shall apply to payments 58
under an APR-DRG or APC model or a managed care program or similar 59
model described in subsection (H) of this section unless 60
specifically authorized by the division. 61
(3) Laboratory and x-ray services. 62
(4) Nursing facility services. 63
(a) The division shall make full payment to 64
nursing facilities for each day, not exceeding forty-two (42) days 65
per year, that a patient is absent from the facility on home 66
leave. Payment may be made for the following home leave days in 67
addition to the forty-two-day limitation: Christmas, the day 68
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before Christmas, the day after Christmas, Thanksgiving, the day 69
before Thanksgiving and the day after Thanksgiving. 70
(b) From and after July 1, 1997, the division 71
shall implement the integrated case-mix payment and quality 72
monitoring system, which includes the fair rental system for 73
property costs and in which recapture of depreciation is 74
eliminated. The division may reduce the payment for hospital 75
leave and therapeutic home leave days to the lower of the case-mix 76
category as computed for the resident on leave using the 77
assessment being utilized for payment at that point in time, or a 78
case-mix score of 1.000 for nursing facilities, and shall compute 79
case-mix scores of residents so that only services provided at the 80
nursing facility are considered in calculating a facility's per 81
diem. 82
(c) From and after July 1, 1997, all state-owned 83
nursing facilities shall be reimbursed on a full reasonable cost 84
basis. 85
(d) On or after January 1, 2015, the division 86
shall update the case-mix payment system resource utilization 87
grouper and classifications and fair rental reimbursement system. 88
The division shall develop and implement a payment add-on to 89
reimburse nursing facilities for ventilator-dependent resident 90
services. 91
(e) The division shall develop and implement, not 92
later than January 1, 2001, a case-mix payment add-on determined 93
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by time studies and other valid statistical data that will 94
reimburse a nursing facility for the additional cost of caring for 95
a resident who has a diagnosis of Alzheimer's or other related 96
dementia and exhibits symptoms that require special care. Any 97
such case-mix add-on payment shall be supported by a determination 98
of additional cost. The division shall also develop and implement 99
as part of the fair rental reimbursement system for nursing 100
facility beds, an Alzheimer's resident bed depreciation enhanced 101
reimbursement system that will provide an incentive to encourage 102
nursing facilities to convert or construct beds for residents with 103
Alzheimer's or other related dementia. 104
(f) The division shall develop and implement an 105
assessment process for long-term care services. The division may 106
provide the assessment and related functions directly or through 107
contract with the area agencies on aging. 108
The division shall apply for necessary federal waivers to 109
assure that additional services providing alternatives to nursing 110
facility care are made available to applicants for nursing 111
facility care. 112
(5) Periodic screening and diagnostic services for 113
individuals under age twenty-one (21) years as are needed to 114
identify physical and mental defects and to provide health care 115
treatment and other measures designed to correct or ameliorate 116
defects and physical and mental illness and conditions discovered 117
by the screening services, regardless of whether these services 118
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are included in the state plan. The division may include in its 119
periodic screening and diagnostic program those discretionary 120
services authorized under the federal regulations adopted to 121
implement Title XIX of the federal Social Security Act, as 122
amended. The division, in obtaining physical therapy services, 123
occupational therapy services, and services for individuals with 124
speech, hearing and language disorders, may enter into a 125
cooperative agreement with the State Department of Education for 126
the provision of those services to handicapped students by public 127
school districts using state funds that are provided from the 128
appropriation to the Department of Education to obtain federal 129
matching funds through the division. The division, in obtaining 130
medical and mental health assessments, treatment, care and 131
services for children who are in, or at risk of being put in, the 132
custody of the Mississippi Department of Human Services may enter 133
into a cooperative agreement with the Mississippi Department of 134
Human Services for the provision of those services using state 135
funds that are provided from the appropriation to the Department 136
of Human Services to obtain federal matching funds through the 137
division. 138
(6) Physician services. Fees for physician's services 139
that are covered only by Medicaid shall be reimbursed at ninety 140
percent (90%) of the rate established on January 1, 2018, and as 141
may be adjusted each July thereafter, under Medicare. The 142
division may provide for a reimbursement rate for physician's 143
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services of up to one hundred percent (100%) of the rate 144
established under Medicare for physician's services that are 145
provided after the normal working hours of the physician, as 146
determined in accordance with regulations of the division. The 147
division may reimburse eligible providers, as determined by the 148
division, for certain primary care services at one hundred percent 149
(100%) of the rate established under Medicare. The division shall 150
reimburse obstetricians and gynecologists for certain primary care 151
services as defined by the division at one hundred percent (100%) 152
of the rate established under Medicare. 153
(7) (a) Home health services for eligible persons, not 154
to exceed in cost the prevailing cost of nursing facility 155
services. All home health visits must be precertified as required 156
by the division. In addition to physicians, certified registered 157
nurse practitioners, physician assistants and clinical nurse 158
specialists are authorized to prescribe or order home health 159
services and plans of care, sign home health plans of care, 160
certify and recertify eligibility for home health services and 161
conduct the required initial face-to-face visit with the recipient 162
of the services. 163
(b) [Repealed] 164
(8) Emergency medical transportation services as 165
determined by the division. 166
(9) Prescription drugs and other covered drugs and 167
services as determined by the division. 168
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The division shall establish a mandatory preferred drug list. 169
Drugs not on the mandatory preferred drug list shall be made 170
available by utilizing prior authorization procedures established 171
by the division. 172
The division may seek to establish relationships with other 173
states in order to lower acquisition costs of prescription drugs 174
to include single-source and innovator multiple-source drugs or 175
generic drugs. In addition, if allowed by federal law or 176
regulation, the division may seek to establish relationships with 177
and negotiate with other countries to facilitate the acquisition 178
of prescription drugs to include single-source and innovator 179
multiple-source drugs or generic drugs, if that will lower the 180
acquisition costs of those prescription drugs. 181
The division may allow for a combination of prescriptions for 182
single-source and innovator multiple-source drugs and generic 183
drugs to meet the needs of the beneficiaries. 184
The executive director may approve specific maintenance drugs 185
for beneficiaries with certain medical conditions, which may be 186
prescribed and dispensed in three-month supply increments. 187
Drugs prescribed for a resident of a psychiatric residential 188
treatment facility must be provided in true unit doses when 189
available. The division may require that drugs not covered by 190
Medicare Part D for a resident of a long-term care facility be 191
provided in true unit doses when available. Those drugs that were 192
originally billed to the division but are not used by a resident 193
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in any of those facilities shall be returned to the billing 194
pharmacy for credit to the division, in accordance with the 195
guidelines of the State Board of Pharmacy and any requirements of 196
federal law and regulation. Drugs shall be dispensed to a 197
recipient and only one (1) dispensing fee per month may be 198
charged. The division shall develop a methodology for reimbursing 199
for restocked drugs, which shall include a restock fee as 200
determined by the division not exceeding Seven Dollars and 201
Eighty-two Cents ($7.82). 202
Except for those specific maintenance drugs approved by the 203
executive director, the division shall not reimburse for any 204
portion of a prescription that exceeds a thirty-one-day supply of 205
the drug based on the daily dosage. 206
The division is authorized to develop and implement a program 207
of payment for additional pharmacist services as determined by the 208
division. 209
All claims for drugs for dually eligible Medicare/Medicaid 210
beneficiaries that are paid for by Medicare must be submitted to 211
Medicare for payment before they may be processed by the 212
division's online payment system. 213
The division shall develop a pharmacy policy in which drugs 214
in tamper-resistant packaging that are prescribed for a resident 215
of a nursing facility but are not dispensed to the resident shall 216
be returned to the pharmacy and not billed to Medicaid, in 217
accordance with guidelines of the State Board of Pharmacy. 218
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The division shall develop and implement a method or methods 219
by which the division will provide on a regular basis to Medicaid 220
providers who are authorized to prescribe drugs, information about 221
the costs to the Medicaid program of single-source drugs and 222
innovator multiple-source drugs, and information about other drugs 223
that may be prescribed as alternatives to those single-source 224
drugs and innovator multiple-source drugs and the costs to the 225
Medicaid program of those alternative drugs. 226
Notwithstanding any law or regulation, information obtained 227
or maintained by the division regarding the prescription drug 228
program, including trade secrets and manufacturer or labeler 229
pricing, is confidential and not subject to disclosure except to 230
other state agencies. 231
The dispensing fee for each new or refill prescription, 232
including nonlegend or over-the-counter drugs covered by the 233
division, shall be not less than Three Dollars and Ninety-one 234
Cents ($3.91), as determined by the division. 235
The division shall not reimburse for single-source or 236
innovator multiple-source drugs if there are equally effective 237
generic equivalents available and if the generic equivalents are 238
the least expensive. 239
It is the intent of the Legislature that the pharmacists 240
providers be reimbursed for the reasonable costs of filling and 241
dispensing prescriptions for Medicaid beneficiaries. 242
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The division shall allow certain drugs, including 243
physician-administered drugs, and implantable drug system devices, 244
and medical supplies, with limited distribution or limited access 245
for beneficiaries and administered in an appropriate clinical 246
setting, to be reimbursed as either a medical claim or pharmacy 247
claim, as determined by the division. 248
It is the intent of the Legislature that the division and any 249
managed care entity described in subsection (H) of this section 250
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 251
prevent recurrent preterm birth. 252
(10) Dental and orthodontic services to be determined 253
by the division. 254
The division shall increase the amount of the reimbursement 255
rate for diagnostic and preventative dental services for each of 256
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 257
the amount of the reimbursement rate for the previous fiscal year. 258
The division shall increase the amount of the reimbursement rate 259
for restorative dental services for each of the fiscal years 2023, 260
2024 and 2025 by five percent (5%) above the amount of the 261
reimbursement rate for the previous fiscal year. It is the intent 262
of the Legislature that the reimbursement rate revision for 263
preventative dental services will be an incentive to increase the 264
number of dentists who actively provide Medicaid services. This 265
dental services reimbursement rate revision shall be known as the 266
"James Russell Dumas Medicaid Dental Services Incentive Program." 267
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The Medical Care Advisory Committee, assisted by the Division 268
of Medicaid, shall annually determine the effect of this incentive 269
by evaluating the number of dentists who are Medicaid providers, 270
the number who and the degree to which they are actively billing 271
Medicaid, the geographic trends of where dentists are offering 272
what types of Medicaid services and other statistics pertinent to 273
the goals of this legislative intent. This data shall annually be 274
presented to the Chair of the Senate Medicaid Committee and the 275
Chair of the House Medicaid Committee. 276
The division shall include dental services as a necessary 277
component of overall health services provided to children who are 278
eligible for services. 279
(11) Eyeglasses for all Medicaid beneficiaries who have 280
(a) had surgery on the eyeball or ocular muscle that results in a 281
vision change for which eyeglasses or a change in eyeglasses is 282
medically indicated within six (6) months of the surgery and is in 283
accordance with policies established by the division, or (b) one 284
(1) pair every five (5) years and in accordance with policies 285
established by the division. In either instance, the eyeglasses 286
must be prescribed by a physician skilled in diseases of the eye 287
or an optometrist, whichever the beneficiary may select. 288
The division shall apply for a waiver of federal law and 289
regulations to allow coverage for an additional pair of eyeglasses 290
within a five-year period for beneficiaries who are twenty-one 291
(21) years of age or older whose refraction has changed within the 292
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five-year period and a physician skilled in diseases of the eye or 293
an optometrist has determined that a new pair of eyeglasses is 294
needed to correct the change in refraction. The division shall 295
implement the provisions of this paragraph upon approval of the 296
necessary waiver. 297
(12) Intermediate care facility services. 298
(a) The division shall make full payment to all 299
intermediate care facilities for individuals with intellectual 300
disabilities for each day, not exceeding sixty-three (63) days per 301
year, that a patient is absent from the facility on home leave. 302
Payment may be made for the following home leave days in addition 303
to the sixty-three-day limitation: Christmas, the day before 304
Christmas, the day after Christmas, Thanksgiving, the day before 305
Thanksgiving and the day after Thanksgiving. 306
(b) All state-owned intermediate care facilities 307
for individuals with intellectual disabilities shall be reimbursed 308
on a full reasonable cost basis. 309
(c) Effective January 1, 2015, the division shall 310
update the fair rental reimbursement system for intermediate care 311
facilities for individuals with intellectual disabilities. 312
(13) Family planning services, including drugs, 313
supplies and devices, when those services are under the 314
supervision of a physician or nurse practitioner. 315
(14) Clinic services. Preventive, diagnostic, 316
therapeutic, rehabilitative or palliative services that are 317
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furnished by a facility that is not part of a hospital but is 318
organized and operated to provide medical care to outpatients. 319
Clinic services include, but are not limited to: 320
(a) Services provided by ambulatory surgical 321
centers (ASCs) as defined in Section 41-75-1(a); and 322
(b) Dialysis center services. 323
(15) Home- and community-based services for the elderly 324
and disabled, as provided under Title XIX of the federal Social 325
Security Act, as amended, under waivers, subject to the 326
availability of funds specifically appropriated for that purpose 327
by the Legislature. 328
(16) Mental health services. Certain services provided 329
by a psychiatrist shall be reimbursed at up to one hundred percent 330
(100%) of the Medicare rate. Approved therapeutic and case 331
management services (a) provided by an approved regional mental 332
health/intellectual disability center established under Sections 333
41-19-31 through 41-19-39, or by another community mental health 334
service provider meeting the requirements of the Department of 335
Mental Health to be an approved mental health/intellectual 336
disability center if determined necessary by the Department of 337
Mental Health, using state funds that are provided in the 338
appropriation to the division to match federal funds, or (b) 339
provided by a facility that is certified by the State Department 340
of Mental Health to provide therapeutic and case management 341
services, to be reimbursed on a fee for service basis, or (c) 342
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provided in the community by a facility or program operated by the 343
Department of Mental Health. Any such services provided by a 344
facility described in subparagraph (b) must have the prior 345
approval of the division to be reimbursable under this section. 346
(17) Durable medical equipment services and medical 347
supplies. Precertification of durable medical equipment and 348
medical supplies must be obtained as required by the division. 349
The Division of Medicaid may require durable medical equipment 350
providers to obtain a surety bond in the amount and to the 351
specifications as established by the Balanced Budget Act of 1997. 352
A maximum dollar amount of reimbursement for noninvasive 353
ventilators or ventilation treatments properly ordered and being 354
used in an appropriate care setting shall not be set by any health 355
maintenance organization, coordinated care organization, 356
provider-sponsored health plan, or other organization paid for 357
services on a capitated basis by the division under any managed 358
care program or coordinated care program implemented by the 359
division under this section. Reimbursement by these organizations 360
to durable medical equipment suppliers for home use of noninvasive 361
and invasive ventilators shall be on a continuous monthly payment 362
basis for the duration of medical need throughout a patient's 363
valid prescription period. 364
(18) (a) Notwithstanding any other provision of this 365
section to the contrary, as provided in the Medicaid state plan 366
amendment or amendments as defined in Section 43-13-145(10), the 367
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division shall make additional reimbursement to hospitals that 368
serve a disproportionate share of low-income patients and that 369
meet the federal requirements for those payments as provided in 370
Section 1923 of the federal Social Security Act and any applicable 371
regulations. It is the intent of the Legislature that the 372
division shall draw down all available federal funds allotted to 373
the state for disproportionate share hospitals. However, from and 374
after January 1, 1999, public hospitals participating in the 375
Medicaid disproportionate share program may be required to 376
participate in an intergovernmental transfer program as provided 377
in Section 1903 of the federal Social Security Act and any 378
applicable regulations. 379
(b) (i) 1. The division may establish a Medicare 380
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 381
the federal Social Security Act and any applicable federal 382
regulations, or an allowable delivery system or provider payment 383
initiative authorized under 42 CFR 438.6(c), for hospitals, 384
nursing facilities and physicians employed or contracted by 385
hospitals. 386
2. The division shall establish a 387
Medicaid Supplemental Payment Program, as permitted by the federal 388
Social Security Act and a comparable allowable delivery system or 389
provider payment initiative authorized under 42 CFR 438.6(c), for 390
emergency ambulance transportation providers in accordance with 391
this subsection (A)(18)(b). 392
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(ii) The division shall assess each hospital, 393
nursing facility, and emergency ambulance transportation provider 394
for the sole purpose of financing the state portion of the 395
Medicare Upper Payment Limits Program or other program(s) 396
authorized under this subsection (A)(18)(b). The hospital 397
assessment shall be as provided in Section 43-13-145(4)(a), and 398
the nursing facility and the emergency ambulance transportation 399
assessments, if established, shall be based on Medicaid 400
utilization or other appropriate method, as determined by the 401
division, consistent with federal regulations. The assessments 402
will remain in effect as long as the state participates in the 403
Medicare Upper Payment Limits Program or other program(s) 404
authorized under this subsection (A)(18)(b). In addition to the 405
hospital assessment provided in Section 43-13-145(4)(a), hospitals 406
with physicians participating in the Medicare Upper Payment Limits 407
Program or other program(s) authorized under this subsection 408
(A)(18)(b) shall be required to participate in an 409
intergovernmental transfer or assessment, as determined by the 410
division, for the purpose of financing the state portion of the 411
physician UPL payments or other payment(s) authorized under this 412
subsection (A)(18)(b). 413
(iii) Subject to approval by the Centers for 414
Medicare and Medicaid Services (CMS) and the provisions of this 415
subsection (A)(18)(b), the division shall make additional 416
reimbursement to hospitals, nursing facilities, and emergency 417
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ambulance transportation providers for the Medicare Upper Payment 418
Limits Program or other program(s) authorized under this 419
subsection (A)(18)(b), and, if the program is established for 420
physicians, shall make additional reimbursement for physicians, as 421
defined in Section 1902(a)(30) of the federal Social Security Act 422
and any applicable federal regulations, provided the assessment in 423
this subsection (A)(18)(b) is in effect. 424
(iv) Notwithstanding any other provision of 425
this article to the contrary, effective upon implementation of the 426
Mississippi Hospital Access Program (MHAP) provided in 427
subparagraph (c)(i) below, the hospital portion of the inpatient 428
Upper Payment Limits Program shall transition into and be replaced 429
by the MHAP program. However, the division is authorized to 430
develop and implement an alternative fee-for-service Upper Payment 431
Limits model in accordance with federal laws and regulations if 432
necessary to preserve supplemental funding. Further, the 433
division, in consultation with the hospital industry shall develop 434
alternative models for distribution of medical claims and 435
supplemental payments for inpatient and outpatient hospital 436
services, and such models may include, but shall not be limited to 437
the following: increasing rates for inpatient and outpatient 438
services; creating a low-income utilization pool of funds to 439
reimburse hospitals for the costs of uncompensated care, charity 440
care and bad debts as permitted and approved pursuant to federal 441
regulations and the Centers for Medicare and Medicaid Services; 442
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supplemental payments based upon Medicaid utilization, quality, 443
service lines and/or costs of providing such services to Medicaid 444
beneficiaries and to uninsured patients. The goals of such 445
payment models shall be to ensure access to inpatient and 446
outpatient care and to maximize any federal funds that are 447
available to reimburse hospitals for services provided. Any such 448
documents required to achieve the goals described in this 449
paragraph shall be submitted to the Centers for Medicare and 450
Medicaid Services, with a proposed effective date of July 1, 2019, 451
to the extent possible, but in no event shall the effective date 452
of such payment models be later than July 1, 2020. The Chairmen 453
of the Senate and House Medicaid Committees shall be provided a 454
copy of the proposed payment model(s) prior to submission. 455
Effective July 1, 2018, and until such time as any payment 456
model(s) as described above become effective, the division, in 457
consultation with the hospital industry, is authorized to 458
implement a transitional program for inpatient and outpatient 459
payments and/or supplemental payments (including, but not limited 460
to, MHAP and directed payments), to redistribute available 461
supplemental funds among hospital providers, provided that when 462
compared to a hospital's prior year supplemental payments, 463
supplemental payments made pursuant to any such transitional 464
program shall not result in a decrease of more than five percent 465
(5%) and shall not increase by more than the amount needed to 466
maximize the distribution of the available funds. 467
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(v) 1. To preserve and improve access to 468
ambulance transportation provider services, the division shall 469
seek CMS approval to make ambulance service access payments as set 470
forth in this subsection (A)(18)(b) for all covered emergency 471
ambulance services rendered on or after July 1, 2022, and shall 472
make such ambulance service access payments for all covered 473
services rendered on or after the effective date of CMS approval. 474
2. The division shall calculate the 475
ambulance service access payment amount as the balance of the 476
portion of the Medical Care Fund related to ambulance 477
transportation service provider assessments plus any federal 478
matching funds earned on the balance, up to, but not to exceed, 479
the upper payment limit gap for all emergency ambulance service 480
providers. 481
3. a. Except for ambulance services 482
exempt from the assessment provided in this paragraph (18)(b), all 483
ambulance transportation service providers shall be eligible for 484
ambulance service access payments each state fiscal year as set 485
forth in this paragraph (18)(b). 486
b. In addition to any other funds 487
paid to ambulance transportation service providers for emergency 488
medical services provided to Medicaid beneficiaries, each eligible 489
ambulance transportation service provider shall receive ambulance 490
service access payments each state fiscal year equal to the 491
ambulance transportation service provider's upper payment limit 492
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gap. Subject to approval by the Centers for Medicare and Medicaid 493
Services, ambulance service access payments shall be made no less 494
than on a quarterly basis. 495
c. As used in this paragraph 496
(18)(b)(v), the term "upper payment limit gap" means the 497
difference between the total amount that the ambulance 498
transportation service provider received from Medicaid and the 499
average amount that the ambulance transportation service provider 500
would have received from commercial insurers for those services 501
reimbursed by Medicaid. 502
4. An ambulance service access payment 503
shall not be used to offset any other payment by the division for 504
emergency or nonemergency services to Medicaid beneficiaries. 505
(c) (i) Not later than December l, 2015, the 506
division shall, subject to approval by the Centers for Medicare 507
and Medicaid Services (CMS), establish, implement and operate a 508
Mississippi Hospital Access Program (MHAP) for the purpose of 509
protecting patient access to hospital care through hospital 510
inpatient reimbursement programs provided in this section designed 511
to maintain total hospital reimbursement for inpatient services 512
rendered by in-state hospitals and the out-of-state hospital that 513
is authorized by federal law to submit intergovernmental transfers 514
(IGTs) to the State of Mississippi and is classified as Level I 515
trauma center located in a county contiguous to the state line at 516
the maximum levels permissible under applicable federal statutes 517
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and regulations, at which time the current inpatient Medicare 518
Upper Payment Limits (UPL) Program for hospital inpatient services 519
shall transition to the MHAP. 520
(ii) Subject to approval by the Centers for 521
Medicare and Medicaid Services (CMS), the MHAP shall provide 522
increased inpatient capitation (PMPM) payments to managed care 523
entities contracting with the division pursuant to subsection (H) 524
of this section to support availability of hospital services or 525
such other payments permissible under federal law necessary to 526
accomplish the intent of this subsection. 527
(iii) The intent of this subparagraph (c) is 528
that effective for all inpatient hospital Medicaid services during 529
state fiscal year 2016, and so long as this provision shall remain 530
in effect hereafter, the division shall to the fullest extent 531
feasible replace the additional reimbursement for hospital 532
inpatient services under the inpatient Medicare Upper Payment 533
Limits (UPL) Program with additional reimbursement under the MHAP 534
and other payment programs for inpatient and/or outpatient 535
payments which may be developed under the authority of this 536
paragraph. 537
(iv) The division shall assess each hospital 538
as provided in Section 43-13-145(4)(a) for the purpose of 539
financing the state portion of the MHAP, supplemental payments and 540
such other purposes as specified in Section 43-13-145. The 541
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assessment will remain in effect as long as the MHAP and 542
supplemental payments are in effect. 543
(19) (a) Perinatal risk management services. The 544
division shall promulgate regulations to be effective from and 545
after October 1, 1988, to establish a comprehensive perinatal 546
system for risk assessment of all pregnant and infant Medicaid 547
recipients and for management, education and follow-up for those 548
who are determined to be at risk. Services to be performed 549
include case management, nutrition assessment/counseling, 550
psychosocial assessment/counseling and health education. The 551
division shall contract with the State Department of Health to 552
provide services within this paragraph (Perinatal High Risk 553
Management/Infant Services System (PHRM/ISS)). The State 554
Department of Health shall be reimbursed on a full reasonable cost 555
basis for services provided under this subparagraph (a). 556
(b) Early intervention system services. The 557
division shall cooperate with the State Department of Health, 558
acting as lead agency, in the development and implementation of a 559
statewide system of delivery of early intervention services, under 560
Part C of the Individuals with Disabilities Education Act (IDEA). 561
The State Department of Health shall certify annually in writing 562
to the executive director of the division the dollar amount of 563
state early intervention funds available that will be utilized as 564
a certified match for Medicaid matching funds. Those funds then 565
shall be used to provide expanded targeted case management 566
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services for Medicaid eligible children with special needs who are 567
eligible for the state's early intervention system. 568
Qualifications for persons providing service coordination shall be 569
determined by the State Department of Health and the Division of 570
Medicaid. 571
(20) Home- and community-based services for physically 572
disabled approved services as allowed by a waiver from the United 573
States Department of Health and Human Services for home- and 574
community-based services for physically disabled people using 575
state funds that are provided from the appropriation to the State 576
Department of Rehabilitation Services and used to match federal 577
funds under a cooperative agreement between the division and the 578
department, provided that funds for these services are 579
specifically appropriated to the Department of Rehabilitation 580
Services. 581
(21) Nurse practitioner services. Services furnished 582
by a registered nurse who is licensed and certified by the 583
Mississippi Board of Nursing as a nurse practitioner, including, 584
but not limited to, nurse anesthetists, nurse midwives, family 585
nurse practitioners, family planning nurse practitioners, 586
pediatric nurse practitioners, obstetrics-gynecology nurse 587
practitioners and neonatal nurse practitioners, under regulations 588
adopted by the division. Reimbursement for those services shall 589
not exceed ninety percent (90%) of the reimbursement rate for 590
comparable services rendered by a physician. The division may 591
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provide for a reimbursement rate for nurse practitioner services 592
of up to one hundred percent (100%) of the reimbursement rate for 593
comparable services rendered by a physician for nurse practitioner 594
services that are provided after the normal working hours of the 595
nurse practitioner, as determined in accordance with regulations 596
of the division. 597
(22) Ambulatory services delivered in federally 598
qualified health centers, rural health centers and clinics of the 599
local health departments of the State Department of Health for 600
individuals eligible for Medicaid under this article based on 601
reasonable costs as determined by the division. Federally 602
qualified health centers shall be reimbursed by the Medicaid 603
prospective payment system as approved by the Centers for Medicare 604
and Medicaid Services. The division shall recognize federally 605
qualified health centers (FQHCs), rural health clinics (RHCs) and 606
community mental health centers (CMHCs) as both an originating and 607
distant site provider for the purposes of telehealth 608
reimbursement. The division is further authorized and directed to 609
reimburse FQHCs, RHCs and CMHCs for both distant site and 610
originating site services when such services are appropriately 611
provided by the same organization. 612
(23) Inpatient psychiatric services. 613
(a) Inpatient psychiatric services to be 614
determined by the division for recipients under age twenty-one 615
(21) that are provided under the direction of a physician in an 616
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inpatient program in a licensed acute care psychiatric facility or 617
in a licensed psychiatric residential treatment facility, before 618
the recipient reaches age twenty-one (21) or, if the recipient was 619
receiving the services immediately before he or she reached age 620
twenty-one (21), before the earlier of the date he or she no 621
longer requires the services or the date he or she reaches age 622
twenty-two (22), as provided by federal regulations. From and 623
after January 1, 2015, the division shall update the fair rental 624
reimbursement system for psychiatric residential treatment 625
facilities. Precertification of inpatient days and residential 626
treatment days must be obtained as required by the division. From 627
and after July 1, 2009, all state-owned and state-operated 628
facilities that provide inpatient psychiatric services to persons 629
under age twenty-one (21) who are eligible for Medicaid 630
reimbursement shall be reimbursed for those services on a full 631
reasonable cost basis. 632
(b) The division may reimburse for services 633
provided by a licensed freestanding psychiatric hospital to 634
Medicaid recipients over the age of twenty-one (21) in a method 635
and manner consistent with the provisions of Section 43-13-117.5. 636
(24) [Deleted] 637
(25) [Deleted] 638
(26) Hospice care. As used in this paragraph, the term 639
"hospice care" means a coordinated program of active professional 640
medical attention within the home and outpatient and inpatient 641
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care that treats the terminally ill patient and family as a unit, 642
employing a medically directed interdisciplinary team. The 643
program provides relief of severe pain or other physical symptoms 644
and supportive care to meet the special needs arising out of 645
physical, psychological, spiritual, social and economic stresses 646
that are experienced during the final stages of illness and during 647
dying and bereavement and meets the Medicare requirements for 648
participation as a hospice as provided in federal regulations. 649
(27) Group health plan premiums and cost-sharing if it 650
is cost-effective as defined by the United States Secretary of 651
Health and Human Services. 652
(28) Other health insurance premiums that are 653
cost-effective as defined by the United States Secretary of Health 654
and Human Services. Medicare eligible must have Medicare Part B 655
before other insurance premiums can be paid. 656
(29) The Division of Medicaid may apply for a waiver 657
from the United States Department of Health and Human Services for 658
home- and community-based services for developmentally disabled 659
people using state funds that are provided from the appropriation 660
to the State Department of Mental Health and/or funds transferred 661
to the department by a political subdivision or instrumentality of 662
the state and used to match federal funds under a cooperative 663
agreement between the division and the department, provided that 664
funds for these services are specifically appropriated to the 665
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Department of Mental Health and/or transferred to the department 666
by a political subdivision or instrumentality of the state. 667
(30) Pediatric skilled nursing services as determined 668
by the division and in a manner consistent with regulations 669
promulgated by the Mississippi State Department of Health. 670
(31) Targeted case management services for children 671
with special needs, under waivers from the United States 672
Department of Health and Human Services, using state funds that 673
are provided from the appropriation to the Mississippi Department 674
of Human Services and used to match federal funds under a 675
cooperative agreement between the division and the department. 676
(32) Care and services provided in Christian Science 677
Sanatoria listed and certified by the Commission for Accreditation 678
of Christian Science Nursing Organizations/Facilities, Inc., 679
rendered in connection with treatment by prayer or spiritual means 680
to the extent that those services are subject to reimbursement 681
under Section 1903 of the federal Social Security Act. 682
(33) Podiatrist services. 683
(34) Assisted living services as provided through 684
home- and community-based services under Title XIX of the federal 685
Social Security Act, as amended, subject to the availability of 686
funds specifically appropriated for that purpose by the 687
Legislature. 688
(35) Services and activities authorized in Sections 689
43-27-101 and 43-27-103, using state funds that are provided from 690
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the appropriation to the Mississippi Department of Human Services 691
and used to match federal funds under a cooperative agreement 692
between the division and the department. 693
(36) Nonemergency transportation services for 694
Medicaid-eligible persons as determined by the division. The PEER 695
Committee shall conduct a performance evaluation of the 696
nonemergency transportation program to evaluate the administration 697
of the program and the providers of transportation services to 698
determine the most cost-effective ways of providing nonemergency 699
transportation services to the patients served under the program. 700
The performance evaluation shall be completed and provided to the 701
members of the Senate Medicaid Committee and the House Medicaid 702
Committee not later than January 1, 2019, and every two (2) years 703
thereafter. 704
(37) [Deleted] 705
(38) Chiropractic services. A chiropractor's manual 706
manipulation of the spine to correct a subluxation, if x-ray 707
demonstrates that a subluxation exists and if the subluxation has 708
resulted in a neuromusculoskeletal condition for which 709
manipulation is appropriate treatment, and related spinal x-rays 710
performed to document these conditions. Reimbursement for 711
chiropractic services shall not exceed Seven Hundred Dollars 712
($700.00) per year per beneficiary. 713
(39) Dually eligible Medicare/Medicaid beneficiaries. 714
The division shall pay the Medicare deductible and coinsurance 715
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amounts for services available under Medicare, as determined by 716
the division. From and after July 1, 2009, the division shall 717
reimburse crossover claims for inpatient hospital services and 718
crossover claims covered under Medicare Part B in the same manner 719
that was in effect on January 1, 2008, unless specifically 720
authorized by the Legislature to change this method. 721
(40) [Deleted] 722
(41) Services provided by the State Department of 723
Rehabilitation Services for the care and rehabilitation of persons 724
with spinal cord injuries or traumatic brain injuries, as allowed 725
under waivers from the United States Department of Health and 726
Human Services, using up to seventy-five percent (75%) of the 727
funds that are appropriated to the Department of Rehabilitation 728
Services from the Spinal Cord and Head Injury Trust Fund 729
established under Section 37-33-261 and used to match federal 730
funds under a cooperative agreement between the division and the 731
department. 732
(42) [Deleted] 733
(43) The division shall provide reimbursement, 734
according to a payment schedule developed by the division, for 735
smoking cessation medications for pregnant women during their 736
pregnancy and other Medicaid-eligible women who are of 737
child-bearing age. 738
(44) Nursing facility services for the severely 739
disabled. 740
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(a) Severe disabilities include, but are not 741
limited to, spinal cord injuries, closed-head injuries and 742
ventilator-dependent patients. 743
(b) Those services must be provided in a long-term 744
care nursing facility dedicated to the care and treatment of 745
persons with severe disabilities. 746
(45) Physician assistant services. Services furnished 747
by a physician assistant who is licensed by the State Board of 748
Medical Licensure and is practicing with physician supervision 749
under regulations adopted by the board, under regulations adopted 750
by the division. Reimbursement for those services shall not 751
exceed ninety percent (90%) of the reimbursement rate for 752
comparable services rendered by a physician. The division may 753
provide for a reimbursement rate for physician assistant services 754
of up to one hundred percent (100%) or the reimbursement rate for 755
comparable services rendered by a physician for physician 756
assistant services that are provided after the normal working 757
hours of the physician assistant, as determined in accordance with 758
regulations of the division. 759
(46) The division shall make application to the federal 760
Centers for Medicare and Medicaid Services (CMS) for a waiver to 761
develop and provide services for children with serious emotional 762
disturbances as defined in Section 43-14-1(1), which may include 763
home- and community-based services, case management services or 764
managed care services through mental health providers certified by 765
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the Department of Mental Health. The division may implement and 766
provide services under this waivered program only if funds for 767
these services are specifically appropriated for this purpose by 768
the Legislature, or if funds are voluntarily provided by affected 769
agencies. 770
(47) (a) The division may develop and implement 771
disease management programs for individuals with high-cost chronic 772
diseases and conditions, including the use of grants, waivers, 773
demonstrations or other projects as necessary. 774
(b) Participation in any disease management 775
program implemented under this paragraph (47) is optional with the 776
individual. An individual must affirmatively elect to participate 777
in the disease management program in order to participate, and may 778
elect to discontinue participation in the program at any time. 779
(48) Pediatric long-term acute care hospital services. 780
(a) Pediatric long-term acute care hospital 781
services means services provided to eligible persons under 782
twenty-one (21) years of age by a freestanding Medicare-certified 783
hospital that has an average length of inpatient stay greater than 784
twenty-five (25) days and that is primarily engaged in providing 785
chronic or long-term medical care to persons under twenty-one (21) 786
years of age. 787
(b) The services under this paragraph (48) shall 788
be reimbursed as a separate category of hospital services. 789
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(49) The division may establish copayments and/or 790
coinsurance for any Medicaid services for which copayments and/or 791
coinsurance are allowable under federal law or regulation. 792
(50) Services provided by the State Department of 793
Rehabilitation Services for the care and rehabilitation of persons 794
who are deaf and blind, as allowed under waivers from the United 795
States Department of Health and Human Services to provide home- 796
and community-based services using state funds that are provided 797
from the appropriation to the State Department of Rehabilitation 798
Services or if funds are voluntarily provided by another agency. 799
(51) Upon determination of Medicaid eligibility and in 800
association with annual redetermination of Medicaid eligibility, 801
beneficiaries shall be encouraged to undertake a physical 802
examination that will establish a base-line level of health and 803
identification of a usual and customary source of care (a medical 804
home) to aid utilization of disease management tools. This 805
physical examination and utilization of these disease management 806
tools shall be consistent with current United States Preventive 807
Services Task Force or other recognized authority recommendations. 808
For persons who are determined ineligible for Medicaid, the 809
division will provide information and direction for accessing 810
medical care and services in the area of their residence. 811
(52) Notwithstanding any provisions of this article, 812
the division may pay enhanced reimbursement fees related to trauma 813
care, as determined by the division in conjunction with the State 814
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Department of Health, using funds appropriated to the State 815
Department of Health for trauma care and services and used to 816
match federal funds under a cooperative agreement between the 817
division and the State Department of Health. The division, in 818
conjunction with the State Department of Health, may use grants, 819
waivers, demonstrations, enhanced reimbursements, Upper Payment 820
Limits Programs, supplemental payments, or other projects as 821
necessary in the development and implementation of this 822
reimbursement program. 823
(53) Targeted case management services for high-cost 824
beneficiaries may be developed by the division for all services 825
under this section. 826
(54) [Deleted] 827
(55) Therapy services. The plan of care for therapy 828
services may be developed to cover a period of treatment for up to 829
six (6) months, but in no event shall the plan of care exceed a 830
six-month period of treatment. The projected period of treatment 831
must be indicated on the initial plan of care and must be updated 832
with each subsequent revised plan of care. Based on medical 833
necessity, the division shall approve certification periods for 834
less than or up to six (6) months, but in no event shall the 835
certification period exceed the period of treatment indicated on 836
the plan of care. The appeal process for any reduction in therapy 837
services shall be consistent with the appeal process in federal 838
regulations. 839
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(56) Prescribed pediatric extended care centers 840
services for medically dependent or technologically dependent 841
children with complex medical conditions that require continual 842
care as prescribed by the child's attending physician, as 843
determined by the division. 844
(57) No Medicaid benefit shall restrict coverage for 845
medically appropriate treatment prescribed by a physician and 846
agreed to by a fully informed individual, or if the individual 847
lacks legal capacity to consent by a person who has legal 848
authority to consent on his or her behalf, based on an 849
individual's diagnosis with a terminal condition. As used in this 850
paragraph (57), "terminal condition" means any aggressive 851
malignancy, chronic end-stage cardiovascular or cerebral vascular 852
disease, or any other disease, illness or condition which a 853
physician diagnoses as terminal. 854
(58) Treatment services for persons with opioid 855
dependency or other highly addictive substance use disorders. The 856
division is authorized to reimburse eligible providers for 857
treatment of opioid dependency and other highly addictive 858
substance use disorders, as determined by the division. Treatment 859
related to these conditions shall not count against any physician 860
visit limit imposed under this section. 861
(59) The division shall allow beneficiaries between the 862
ages of ten (10) and eighteen (18) years to receive vaccines 863
through a pharmacy venue. The division and the State Department 864
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of Health shall coordinate and notify OB-GYN providers that the 865
Vaccines for Children program is available to providers free of 866
charge. 867
(60) Border city university-affiliated pediatric 868
teaching hospital. 869
(a) Payments may only be made to a border city 870
university-affiliated pediatric teaching hospital if the Centers 871
for Medicare and Medicaid Services (CMS) approve an increase in 872
the annual request for the provider payment initiative authorized 873
under 42 CFR Section 438.6(c) in an amount equal to or greater 874
than the estimated annual payment to be made to the border city 875
university-affiliated pediatric teaching hospital. The estimate 876
shall be based on the hospital's prior year Mississippi managed 877
care utilization. 878
(b) As used in this paragraph (60), the term 879
"border city university-affiliated pediatric teaching hospital" 880
means an out-of-state hospital located within a city bordering the 881
eastern bank of the Mississippi River and the State of Mississippi 882
that submits to the division a copy of a current and effective 883
affiliation agreement with an accredited university and other 884
documentation establishing that the hospital is 885
university-affiliated, is licensed and designated as a pediatric 886
hospital or pediatric primary hospital within its home state, 887
maintains at least five (5) different pediatric specialty training 888
programs, and maintains at least one hundred (100) operated beds 889
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dedicated exclusively for the treatment of patients under the age 890
of twenty-one (21) years. 891
(c) The cost of providing services to Mississippi 892
Medicaid beneficiaries under the age of twenty-one (21) years who 893
are treated by a border city university-affiliated pediatric 894
teaching hospital shall not exceed the cost of providing the same 895
services to individuals in hospitals in the state. 896
(d) It is the intent of the Legislature that 897
payments shall not result in any in-state hospital receiving 898
payments lower than they would otherwise receive if not for the 899
payments made to any border city university-affiliated pediatric 900
teaching hospital. 901
(e) This paragraph (60) shall stand repealed on 902
July 1, 2024. 903
(61) Services described in Section 41-140-3 that are 904
provided by certified community health workers employed and 905
supervised by a Medicaid provider. Reimbursement for these 906
services shall be provided only if the division has received 907
approval from the Centers for Medicare and Medicaid Services for a 908
state plan amendment, waiver or alternative payment model for 909
services delivered by certified community health workers. 910
(B) Planning and development districts participating in the 911
home- and community-based services program for the elderly and 912
disabled as case management providers shall be reimbursed for case 913
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management services at the maximum rate approved by the Centers 914
for Medicare and Medicaid Services (CMS). 915
(C) The division may pay to those providers who participate 916
in and accept patient referrals from the division's emergency room 917
redirection program a percentage, as determined by the division, 918
of savings achieved according to the performance measures and 919
reduction of costs required of that program. Federally qualified 920
health centers may participate in the emergency room redirection 921
program, and the division may pay those centers a percentage of 922
any savings to the Medicaid program achieved by the centers' 923
accepting patient referrals through the program, as provided in 924
this subsection (C). 925
(D) (1) As used in this subsection (D), the following terms 926
shall be defined as provided in this paragraph, except as 927
otherwise provided in this subsection: 928
(a) "Committees" means the Medicaid Committees of 929
the House of Representatives and the Senate, and "committee" means 930
either one of those committees. 931
(b) "Rate change" means an increase, decrease or 932
other change in the payments or rates of reimbursement, or a 933
change in any payment methodology that results in an increase, 934
decrease or other change in the payments or rates of 935
reimbursement, to any Medicaid provider that renders any services 936
authorized to be provided to Medicaid recipients under this 937
article. 938
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(2) Whenever the Division of Medicaid proposes a rate 939
change, the division shall give notice to the chairmen of the 940
committees at least thirty (30) calendar days before the proposed 941
rate change is scheduled to take effect. The division shall 942
furnish the chairmen with a concise summary of each proposed rate 943
change along with the notice, and shall furnish the chairmen with 944
a copy of any proposed rate change upon request. The division 945
also shall provide a summary and copy of any proposed rate change 946
to any other member of the Legislature upon request. 947
(3) If the chairman of either committee or both 948
chairmen jointly object to the proposed rate change or any part 949
thereof, the chairman or chairmen shall notify the division and 950
provide the reasons for their objection in writing not later than 951
seven (7) calendar days after receipt of the notice from the 952
division. The chairman or chairmen may make written 953
recommendations to the division for changes to be made to a 954
proposed rate change. 955
(4) (a) The chairman of either committee or both 956
chairmen jointly may hold a committee meeting to review a proposed 957
rate change. If either chairman or both chairmen decide to hold a 958
meeting, they shall notify the division of their intention in 959
writing within seven (7) calendar days after receipt of the notice 960
from the division, and shall set the date and time for the meeting 961
in their notice to the division, which shall not be later than 962
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fourteen (14) calendar days after receipt of the notice from the 963
division. 964
(b) After the committee meeting, the committee or 965
committees may object to the proposed rate change or any part 966
thereof. The committee or committees shall notify the division 967
and the reasons for their objection in writing not later than 968
seven (7) calendar days after the meeting. The committee or 969
committees may make written recommendations to the division for 970
changes to be made to a proposed rate change. 971
(5) If both chairmen notify the division in writing 972
within seven (7) calendar days after receipt of the notice from 973
the division that they do not object to the proposed rate change 974
and will not be holding a meeting to review the proposed rate 975
change, the proposed rate change will take effect on the original 976
date as scheduled by the division or on such other date as 977
specified by the division. 978
(6) (a) If there are any objections to a proposed rate 979
change or any part thereof from either or both of the chairmen or 980
the committees, the division may withdraw the proposed rate 981
change, make any of the recommended changes to the proposed rate 982
change, or not make any changes to the proposed rate change. 983
(b) If the division does not make any changes to 984
the proposed rate change, it shall notify the chairmen of that 985
fact in writing, and the proposed rate change shall take effect on 986
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the original date as scheduled by the division or on such other 987
date as specified by the division. 988
(c) If the division makes any changes to the 989
proposed rate change, the division shall notify the chairmen of 990
its actions in writing, and the revised proposed rate change shall 991
take effect on the date as specified by the division. 992
(7) Nothing in this subsection (D) shall be construed 993
as giving the chairmen or the committees any authority to veto, 994
nullify or revise any rate change proposed by the division. The 995
authority of the chairmen or the committees under this subsection 996
shall be limited to reviewing, making objections to and making 997
recommendations for changes to rate changes proposed by the 998
division. 999
(E) Notwithstanding any provision of this article, no new 1000
groups or categories of recipients and new types of care and 1001
services may be added without enabling legislation from the 1002
Mississippi Legislature, except that the division may authorize 1003
those changes without enabling legislation when the addition of 1004
recipients or services is ordered by a court of proper authority. 1005
(F) The executive director shall keep the Governor advised 1006
on a timely basis of the funds available for expenditure and the 1007
projected expenditures. Notwithstanding any other provisions of 1008
this article, if current or projected expenditures of the division 1009
are reasonably anticipated to exceed the amount of funds 1010
appropriated to the division for any fiscal year, the Governor, 1011
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after consultation with the executive director, shall take all 1012
appropriate measures to reduce costs, which may include, but are 1013
not limited to: 1014
(1) Reducing or discontinuing any or all services that 1015
are deemed to be optional under Title XIX of the Social Security 1016
Act; 1017
(2) Reducing reimbursement rates for any or all service 1018
types; 1019
(3) Imposing additional assessments on health care 1020
providers; or 1021
(4) Any additional cost-containment measures deemed 1022
appropriate by the Governor. 1023
To the extent allowed under federal law, any reduction to 1024
services or reimbursement rates under this subsection (F) shall be 1025
accompanied by a reduction, to the fullest allowable amount, to 1026
the profit margin and administrative fee portions of capitated 1027
payments to organizations described in paragraph (1) of subsection 1028
(H). 1029
Beginning in fiscal year 2010 and in fiscal years thereafter, 1030
when Medicaid expenditures are projected to exceed funds available 1031
for the fiscal year, the division shall submit the expected 1032
shortfall information to the PEER Committee not later than 1033
December 1 of the year in which the shortfall is projected to 1034
occur. PEER shall review the computations of the division and 1035
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report its findings to the Legislative Budget Office not later 1036
than January 7 in any year. 1037
(G) Notwithstanding any other provision of this article, it 1038
shall be the duty of each provider participating in the Medicaid 1039
program to keep and maintain books, documents and other records as 1040
prescribed by the Division of Medicaid in accordance with federal 1041
laws and regulations. 1042
(H) (1) Notwithstanding any other provision of this 1043
article, the division is authorized to implement (a) a managed 1044
care program, (b) a coordinated care program, (c) a coordinated 1045
care organization program, (d) a health maintenance organization 1046
program, (e) a patient-centered medical home program, (f) an 1047
accountable care organization program, (g) provider-sponsored 1048
health plan, or (h) any combination of the above programs. As a 1049
condition for the approval of any program under this subsection 1050
(H)(1), the division shall require that no managed care program, 1051
coordinated care program, coordinated care organization program, 1052
health maintenance organization program, or provider-sponsored 1053
health plan may: 1054
(a) Pay providers at a rate that is less than the 1055
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1056
reimbursement rate; 1057
(b) Override the medical decisions of hospital 1058
physicians or staff regarding patients admitted to a hospital for 1059
an emergency medical condition as defined by 42 US Code Section 1060
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1395dd. This restriction (b) does not prohibit the retrospective 1061
review of the appropriateness of the determination that an 1062
emergency medical condition exists by chart review or coding 1063
algorithm, nor does it prohibit prior authorization for 1064
nonemergency hospital admissions; 1065
(c) Pay providers at a rate that is less than the 1066
normal Medicaid reimbursement rate. It is the intent of the 1067
Legislature that all managed care entities described in this 1068
subsection (H), in collaboration with the division, develop and 1069
implement innovative payment models that incentivize improvements 1070
in health care quality, outcomes, or value, as determined by the 1071
division. Participation in the provider network of any managed 1072
care, coordinated care, provider-sponsored health plan, or similar 1073
contractor shall not be conditioned on the provider's agreement to 1074
accept such alternative payment models; 1075
(d) Implement a prior authorization and 1076
utilization review program for medical services, transportation 1077
services and prescription drugs that is more stringent than the 1078
prior authorization processes used by the division in its 1079
administration of the Medicaid program. Not later than December 1080
2, 2021, the contractors that are receiving capitated payments 1081
under a managed care delivery system established under this 1082
subsection (H) shall submit a report to the Chairmen of the House 1083
and Senate Medicaid Committees on the status of the prior 1084
authorization and utilization review program for medical services, 1085
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transportation services and prescription drugs that is required to 1086
be implemented under this subparagraph (d); 1087
(e) [Deleted] 1088
(f) Implement a preferred drug list that is more 1089
stringent than the mandatory preferred drug list established by 1090
the division under subsection (A)(9) of this section; 1091
(g) Implement a policy which denies beneficiaries 1092
with hemophilia access to the federally funded hemophilia 1093
treatment centers as part of the Medicaid Managed Care network of 1094
providers. 1095
Each health maintenance organization, coordinated care 1096
organization, provider-sponsored health plan, or other 1097
organization paid for services on a capitated basis by the 1098
division under any managed care program or coordinated care 1099
program implemented by the division under this section shall use a 1100
clear set of level of care guidelines in the determination of 1101
medical necessity and in all utilization management practices, 1102
including the prior authorization process, concurrent reviews, 1103
retrospective reviews and payments, that are consistent with 1104
widely accepted professional standards of care. Organizations 1105
participating in a managed care program or coordinated care 1106
program implemented by the division may not use any additional 1107
criteria that would result in denial of care that would be 1108
determined appropriate and, therefore, medically necessary under 1109
those levels of care guidelines. 1110
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(2) Notwithstanding any provision of this section, the 1111
recipients eligible for enrollment into a Medicaid Managed Care 1112
Program authorized under this subsection (H) may include only 1113
those categories of recipients eligible for participation in the 1114
Medicaid Managed Care Program as of January 1, 2021, the 1115
Children's Health Insurance Program (CHIP), and the CMS-approved 1116
Section 1115 demonstration waivers in operation as of January 1, 1117
2021. No expansion of Medicaid Managed Care Program contracts may 1118
be implemented by the division without enabling legislation from 1119
the Mississippi Legislature. 1120
(3) (a) Any contractors receiving capitated payments 1121
under a managed care delivery system established in this section 1122
shall provide to the Legislature and the division statistical data 1123
to be shared with provider groups in order to improve patient 1124
access, appropriate utilization, cost savings and health outcomes 1125
not later than October 1 of each year. Additionally, each 1126
contractor shall disclose to the Chairmen of the Senate and House 1127
Medicaid Committees the administrative expenses costs for the 1128
prior calendar year, and the number of full-equivalent employees 1129
located in the State of Mississippi dedicated to the Medicaid and 1130
CHIP lines of business as of June 30 of the current year. 1131
(b) The division and the contractors participating 1132
in the managed care program, a coordinated care program or a 1133
provider-sponsored health plan shall be subject to annual program 1134
reviews or audits performed by the Office of the State Auditor, 1135
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the PEER Committee, the Department of Insurance and/or independent 1136
third parties. 1137
(c) Those reviews shall include, but not be 1138
limited to, at least two (2) of the following items: 1139
(i) The financial benefit to the State of 1140
Mississippi of the managed care program, 1141
(ii) The difference between the premiums paid 1142
to the managed care contractors and the payments made by those 1143
contractors to health care providers, 1144
(iii) Compliance with performance measures 1145
required under the contracts, 1146
(iv) Administrative expense allocation 1147
methodologies, 1148
(v) Whether nonprovider payments assigned as 1149
medical expenses are appropriate, 1150
(vi) Capitated arrangements with related 1151
party subcontractors, 1152
(vii) Reasonableness of corporate 1153
allocations, 1154
(viii) Value-added benefits and the extent to 1155
which they are used, 1156
(ix) The effectiveness of subcontractor 1157
oversight, including subcontractor review, 1158
(x) Whether health care outcomes have been 1159
improved, and 1160
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(xi) The most common claim denial codes to 1161
determine the reasons for the denials. 1162
The audit reports shall be considered public documents and 1163
shall be posted in their entirety on the division's website. 1164
(4) All health maintenance organizations, coordinated 1165
care organizations, provider-sponsored health plans, or other 1166
organizations paid for services on a capitated basis by the 1167
division under any managed care program or coordinated care 1168
program implemented by the division under this section shall 1169
reimburse all providers in those organizations at rates no lower 1170
than those provided under this section for beneficiaries who are 1171
not participating in those programs. 1172
(5) No health maintenance organization, coordinated 1173
care organization, provider-sponsored health plan, or other 1174
organization paid for services on a capitated basis by the 1175
division under any managed care program or coordinated care 1176
program implemented by the division under this section shall 1177
require its providers or beneficiaries to use any pharmacy that 1178
ships, mails or delivers prescription drugs or legend drugs or 1179
devices. 1180
(6) (a) Not later than December 1, 2021, the 1181
contractors who are receiving capitated payments under a managed 1182
care delivery system established under this subsection (H) shall 1183
develop and implement a uniform credentialing process for 1184
providers. Under that uniform credentialing process, a provider 1185
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who meets the criteria for credentialing will be credentialed with 1186
all of those contractors and no such provider will have to be 1187
separately credentialed by any individual contractor in order to 1188
receive reimbursement from the contractor. Not later than 1189
December 2, 2021, those contractors shall submit a report to the 1190
Chairmen of the House and Senate Medicaid Committees on the status 1191
of the uniform credentialing process for providers that is 1192
required under this subparagraph (a). 1193
(b) If those contractors have not implemented a 1194
uniform credentialing process as described in subparagraph (a) by 1195
December 1, 2021, the division shall develop and implement, not 1196
later than July 1, 2022, a single, consolidated credentialing 1197
process by which all providers will be credentialed. Under the 1198
division's single, consolidated credentialing process, no such 1199
contractor shall require its providers to be separately 1200
credentialed by the contractor in order to receive reimbursement 1201
from the contractor, but those contractors shall recognize the 1202
credentialing of the providers by the division's credentialing 1203
process. 1204
(c) The division shall require a uniform provider 1205
credentialing application that shall be used in the credentialing 1206
process that is established under subparagraph (a) or (b). If the 1207
contractor or division, as applicable, has not approved or denied 1208
the provider credentialing application within sixty (60) days of 1209
receipt of the completed application that includes all required 1210
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information necessary for credentialing, then the contractor or 1211
division, upon receipt of a written request from the applicant and 1212
within five (5) business days of its receipt, shall issue a 1213
temporary provider credential/enrollment to the applicant if the 1214
applicant has a valid Mississippi professional or occupational 1215
license to provide the health care services to which the 1216
credential/enrollment would apply. The contractor or the division 1217
shall not issue a temporary credential/enrollment if the applicant 1218
has reported on the application a history of medical or other 1219
professional or occupational malpractice claims, a history of 1220
substance abuse or mental health issues, a criminal record, or a 1221
history of medical or other licensing board, state or federal 1222
disciplinary action, including any suspension from participation 1223
in a federal or state program. The temporary 1224
credential/enrollment shall be effective upon issuance and shall 1225
remain in effect until the provider's credentialing/enrollment 1226
application is approved or denied by the contractor or division. 1227
The contractor or division shall render a final decision regarding 1228
credentialing/enrollment of the provider within sixty (60) days 1229
from the date that the temporary provider credential/enrollment is 1230
issued to the applicant. 1231
(d) If the contractor or division does not render 1232
a final decision regarding credentialing/enrollment of the 1233
provider within the time required in subparagraph (c), the 1234
provider shall be deemed to be credentialed by and enrolled with 1235
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all of the contractors and eligible to receive reimbursement from 1236
the contractors. 1237
(7) (a) Each contractor that is receiving capitated 1238
payments under a managed care delivery system established under 1239
this subsection (H) shall provide to each provider for whom the 1240
contractor has denied the coverage of a procedure that was ordered 1241
or requested by the provider for or on behalf of a patient, a 1242
letter that provides a detailed explanation of the reasons for the 1243
denial of coverage of the procedure and the name and the 1244
credentials of the person who denied the coverage. The letter 1245
shall be sent to the provider in electronic format. 1246
(b) After a contractor that is receiving capitated 1247
payments under a managed care delivery system established under 1248
this subsection (H) has denied coverage for a claim submitted by a 1249
provider, the contractor shall issue to the provider within sixty 1250
(60) days a final ruling of denial of the claim that allows the 1251
provider to have a state fair hearing and/or agency appeal with 1252
the division. If a contractor does not issue a final ruling of 1253
denial within sixty (60) days as required by this subparagraph 1254
(b), the provider's claim shall be deemed to be automatically 1255
approved and the contractor shall pay the amount of the claim to 1256
the provider. 1257
(c) After a contractor has issued a final ruling 1258
of denial of a claim submitted by a provider, the division shall 1259
conduct a state fair hearing and/or agency appeal on the matter of 1260
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the disputed claim between the contractor and the provider within 1261
sixty (60) days, and shall render a decision on the matter within 1262
thirty (30) days after the date of the hearing and/or appeal. 1263
(8) It is the intention of the Legislature that the 1264
division evaluate the feasibility of using a single vendor to 1265
administer pharmacy benefits provided under a managed care 1266
delivery system established under this subsection (H). Providers 1267
of pharmacy benefits shall cooperate with the division in any 1268
transition to a carve-out of pharmacy benefits under managed care. 1269
(9) The division shall evaluate the feasibility of 1270
using a single vendor to administer dental benefits provided under 1271
a managed care delivery system established in this subsection (H). 1272
Providers of dental benefits shall cooperate with the division in 1273
any transition to a carve-out of dental benefits under managed 1274
care. 1275
(10) It is the intent of the Legislature that any 1276
contractor receiving capitated payments under a managed care 1277
delivery system established in this section shall implement 1278
innovative programs to improve the health and well-being of 1279
members diagnosed with prediabetes and diabetes. 1280
(11) It is the intent of the Legislature that any 1281
contractors receiving capitated payments under a managed care 1282
delivery system established under this subsection (H) shall work 1283
with providers of Medicaid services to improve the utilization of 1284
long-acting reversible contraceptives (LARCs). Not later than 1285
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December 1, 2021, any contractors receiving capitated payments 1286
under a managed care delivery system established under this 1287
subsection (H) shall provide to the Chairmen of the House and 1288
Senate Medicaid Committees and House and Senate Public Health 1289
Committees a report of LARC utilization for State Fiscal Years 1290
2018 through 2020 as well as any programs, initiatives, or efforts 1291
made by the contractors and providers to increase LARC 1292
utilization. This report shall be updated annually to include 1293
information for subsequent state fiscal years. 1294
(12) The division is authorized to make not more than 1295
one (1) emergency extension of the contracts that are in effect on 1296
July 1, 2021, with contractors who are receiving capitated 1297
payments under a managed care delivery system established under 1298
this subsection (H), as provided in this paragraph (12). The 1299
maximum period of any such extension shall be one (1) year, and 1300
under any such extensions, the contractors shall be subject to all 1301
of the provisions of this subsection (H). The extended contracts 1302
shall be revised to incorporate any provisions of this subsection 1303
(H). 1304
(I) [Deleted] 1305
(J) There shall be no cuts in inpatient and outpatient 1306
hospital payments, or allowable days or volumes, as long as the 1307
hospital assessment provided in Section 43-13-145 is in effect. 1308
This subsection (J) shall not apply to decreases in payments that 1309
are a result of: reduced hospital admissions, audits or payments 1310
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ST: Medicaid; division shall seek waiver to
allow coverage for additional eyeglasses within
5-year period for adults whose refraction has
changed.
under the APR-DRG or APC models, or a managed care program or 1311
similar model described in subsection (H) of this section. 1312
(K) In the negotiation and execution of such contracts 1313
involving services performed by actuarial firms, the Executive 1314
Director of the Division of Medicaid may negotiate a limitation on 1315
liability to the state of prospective contractors. 1316
(L) The Division of Medicaid shall reimburse for services 1317
provided to eligible Medicaid beneficiaries by a licensed birthing 1318
center in a method and manner to be determined by the division in 1319
accordance with federal laws and federal regulations. The 1320
division shall seek any necessary waivers, make any required 1321
amendments to its State Plan or revise any contracts authorized 1322
under subsection (H) of this section as necessary to provide the 1323
services authorized under this subsection. As used in this 1324
subsection, the term "birthing centers" shall have the meaning as 1325
defined in Section 41-77-1(a), which is a publicly or privately 1326
owned facility, place or institution constructed, renovated, 1327
leased or otherwise established where nonemergency births are 1328
planned to occur away from the mother's usual residence following 1329
a documented period of prenatal care for a normal uncomplicated 1330
pregnancy which has been determined to be low risk through a 1331
formal risk-scoring examination. 1332
(M) This section shall stand repealed on July 1, 2028. 1333
SECTION 2. This act shall take effect and be in force from 1334
and after July 1, 2026. 1335